Bill > A1858

Introduced Session

This bill requires health insurance carriers to provide continued coverage of prescription drugs for covered persons diagnosed with a complex or chronic medical condition or a rare disease. The bill defines "complex or chronic medical condition" as a physical, behavioral, or developmental condition that does not have a known cure or that can be severely debilitating or fatal if left untreated or undertreated. "Rare disease" is defined as any disease or condition that affects less than 200,000 persons in the United States. This bill requires hospital, medical and health service corporations, commercial insurers, health maintenance organizations, health benefits plans issued pursuant to the New Jersey Individual Health Coverage and Small Employer Health Benefits Programs, prepaid prescription service organizations, and plans provided by the State Health Benefits Commission and the School Employees' Health Benefits Commission to provide continued coverage of a prescription drug prescribed for a complex or chronic medical condition or rare disease when the drug: (1) was previously covered by the carrier; and (2) the prescribing provider continues to prescribe the drug for the medical condition or disease, provided the drug is appropriately prescribed, and neither of the following has occurred: · the United States Food and Drug Administration has issued a notice, guidance, warning, announcement, or any other statement about the drug which calls into question the clinical safety of the drug; or · the manufacturer of the drug has notified the United States Food and Drug Administration of any manufacturing discontinuance or potential discontinuance as required by 21 U.S.C. s.356c. The bill also provides that with respect to a drug for a covered person with a complex or chronic condition or a rare disease, in situations in which a covered person appeals a denial of coverage for the drug based on medical necessity, while the appeal is in any stage of the appeals process, the provisions of the contract or policy shall not apply so as to: (1) set forth limitations on maximum coverage of prescription drug benefits; (2) subject the covered person to increased out-of-pocket costs; or (3) move a drug for a covered person to a more restrictive tier, if the contract or policy uses a formulary with tiers.

AI Summary

Committee Categories

Daniel Benson (D)*,  Pam Lampitt (D)*,  Valerie Vainieri Huttle (D)*,  Nicholas Chiaravalloti (D),  Angela Mcknight (D),  Gary Schaer (D), 

Reported as an Assembly Committee Substitute and Referred to Assembly Appropriations Committee (on 12/03/2018)